Diverse stakeholders—clinicians, researchers, business leaders, policy makers, and the public—have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents.
There are limited data regarding implementing electronic health records (EHR) in underserved settings. We evaluated the implementation of an EHR within the Indian Health Service (IHS), a federally funded health system for Native Americans.
We surveyed 223 primary care clinicians practicing at 26 IHS health centers that implemented an EHR between 2003 and 2005.
The survey instrument assessed clinician attitudes regarding EHR implementation, current utilization of individual EHR functions, and attitudes regarding the use of information technology to improve quality of care in underserved settings. We fit a multivariable logistic regression model to identify correlates of increased utilization of the EHR.
The overall response rate was 56%. Of responding clinicians, 66% felt that the EHR implementation process was positive. One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased the quality of the patient–doctor interaction. One-third of clinicians (34%) reported consistent use of electronic reminders, and self-report that EHRs improve quality was strongly associated with increased utilization of the EHR (odds ratio 3.03, 95% confidence interval 1.05–8.8). The majority (87%) of clinicians felt that information technology could potentially improve quality of care in rural and underserved settings through the use of tools such as online information sources, telemedicine programs, and electronic health records.
Clinicians support the use of information technology to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the IHS, potentially due to limited use of key functions within the EHR.
Current models for implementing electronic health records (EHRs) in resource-limited settings may not be scalable because they fail to address human-resource and cost constraints. This paper describes an implementation model which relies on shared responsibility between local sites and an external three-pronged support infrastructure consisting of: (1) a national technical expertise center, (2) an implementer's community, and (3) a developer's community. This model was used to implement an open-source EHR in three Ugandan HIV-clinics. Pre–post time–motion study at one site revealed that Primary Care Providers spent a third less time in direct and indirect care of patients (p<0.001) and 40% more time on personal activities (p=0.09) after EHRs implementation. Time spent by previously enrolled patients with non-clinician staff fell by half (p=0.004) and with pharmacy by 63% (p<0.001). Surveyed providers were highly satisfied with the EHRs and its support infrastructure. This model offers a viable approach for broadly implementing EHRs in resource-limited settings.
Medical records systems; computerized; implementation model; developing countries; time-motion studies
Physicians can receive federal payments for meaningful use of complete certified electronic health records (EHRs). Evidence is limited on how EHR use affects clinical care and outcomes.
To examine the association between use of a commercially available certified EHR and clinical care processes and disease control in patients with diabetes.
Quasi-experimental design with outpatient EHR implementation sequentially across 17 medical centers. Multivariate analyses adjusted for patient characteristics, medical center, time trends, and patient-level clustering.
Kaiser Permanente Northern California, an integrated delivery system.
169 711 patients with diabetes mellitus.
Use of a commercially available certified EHR.
Drug treatment intensification and hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) testing and values.
Use of an EHR was associated with statistically significant improvements in treatment intensification after HbA1c values of 9% or greater (odds ratio, 1.10 [95% CI, 1.06 to 1.14]) or LDL-C values of 2.6 to 3.3 mmol/L (100 to 129 mg/dL) (odds ratio, 1.06 [CI, 1.03 to 1.09]); increases in 365-day retesting for HbA1c and LDL-C levels among all patients, with the most dramatic change among patients with the worst disease control (HbA1c ≥9% or LDL-C ≥3.4 mmol/L [ ≥130 mg/dL]); and decreased 90-day retesting among patients with HbA1c level less than 7% or LDL-C level less than 2.6 mmol/L (<100 mg/dL). The EHR was also associated with statistically significant reductions in HbA1c and LDL-C levels, with the largest reductions among patients with the worst control (0.06-mmol/L [2.19-mg/dL] reduction among patients with baseline LDL-C ≥3.4 mmol/L [ ≥130 mg/dL]; P < 0.001).
The EHR was implemented in a setting with strong baseline performance on cardiovascular care quality measures.
Use of a commercially available, certified EHR was associated with improved drug treatment intensification, monitoring, and physiologic control among patients with diabetes, with greater improvements among patients with worse control and less testing in patients already meeting guideline-recommended glycemic and lipid targets.
Primary Funding Source
National Institute of Diabetes and Digestive and Kidney Diseases.
This article examines the role that clinical workflow plays in successful implementation and meaningful use of electronic health record (EHR) technology in ambulatory care. The benefits and barriers of implementing EHRs in ambulatory care settings are discussed. The researchers conclude that widespread adoption and meaningful use of EHR technology rely on the successful integration of health information technology (HIT) into clinical workflow. Without successful integration of HIT into clinical workflow, clinicians in today's ambulatory care settings will continue to resist adoption and implementation of EHR technology.
electronic health record (EHR); health information technology (HIT); clinical workflow; productivity; meaningful use; ambulatory care
Meaningful use of electronic health records (EHRs) is dependent on accurate clinical documentation. Documenting common goals in the intensive care unit (ICU), such as sedation and ventilator management plans, may increase collaboration and decrease patient length of stay. This study analyzed the degree to which goals stated were present in the EHR.
Descriptive correlational study of common goals verbally stated during daily ICU interdisciplinary rounds compared with the presence of those goals, and actions related to those goals, documented in the EHR over the subsequent 24 h for 28 patients over 15 days. The study setting was a neurovascular ICU with a fully implemented electronic nursing and physician documentation system.
Descriptive statistics and χ2 analyses were used to assess differences in EHR documentation of stated goals and goal-related actions. Inter-coder reliability was performed on 16 (13%) of the 127 stated goals.
One-quarter of the stated goals were not documented in the EHR. If a goal was not documented, actions related to that goal were 60% less likely to be documented. The attending physician note contained 81% of the stated ventilator weaning goals, but only 49% of the sedation weaning goals; additionally, sedation goals were not part of the structured nursing documentation. Inter-coder reliability (κ) was greater than 0.82.
Observations in a single ICU setting at a large academic medical center using a commercial EHR.
The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care.
To assess intensive care unit (ICU) nurses' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance.
The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation.
Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet.
On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months.
As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation.
Human factors; EHR; Geisinger
Integrating clinical research data entry with patient care data entry is a challenging issue. At the G. Pompidou European Hospital (HEGP), cardiovascular radiology reports are captured twice, first in the Electronic Health Record (EHR) and then in a national clinical research server. Informatics standards are different for EHR (HL7 CDA) and clinical research (CDISC ODM). The objective of this work is to feed both the EHR and a Clinical Research Data Management System (CDMS) from a single multipurpose form. We adopted and compared two approaches. First approach consists in implementing the single “care-research” form within the EHR and aligning XML structures of HL7 CDA document and CDISC ODM message to export relevant data from EHR to CDMS. Second approach consists in displaying a single “care-research” XForms form within the EHR and generating both HL7 CDA document and CDISC message to feed both EHR and CDMS. The solution based on XForms avoids overloading both EHR and CDMS with irrelevant information. Beyond syntactic interoperability, a perspective is to address the issue of semantic interoperability between both domains.
HL7; CDA; CDISC; ODM; Medical Records Systems; Computerized; Biomedical Research; Clinical trial; Radiology; Interventional; Cardiovascular systems
Moving from paper records to electronic health records (EHRs) has been a challenge for many Alabama hospitals. Implementation of this innovative technology will assist in providing better patient care by allowing for and providing more accurate and available patient information. The purposes of this study were to assess
the status of implementation of EHRs among Alabama hospitals;the factors that are associated with EHR implementation; andthe benefits of, barriers to, and risks of EHR implementation.
A self-completed survey was mailed to 131 directors in the health information management (HIM) department of Alabama hospitals. Of 91 responding hospitals (69 percent response rate), only 12.0 percent have completed implementation of EHRs. The key factor driving electronic health record (EHR) implementation was to improve clinical processes or workflow efficiency. Lack of adequate funding and resources was the major barrier to EHR implementation. Rural hospitals were less likely to implement EHRs when compared with urban hospitals (p = .07). Adoption of EHRs should be evaluated in depth for hospitals, and particularly for rural hospitals. Ways to seek appropriate funding and provide adequate resources should be explored.
Electronic health records; barriers; benefits; implementation; rural hospitals
To examine common themes about implementing and adopting electronic health record (EHR) systems that emerged from 3 separate studies of the experiences of primary health care providers and those who implement EHRs.
Synthesis of the findings of 3 qualitative studies.
Primary health care practices in southwestern Ontario and the Centre for Studies in Family Medicine at The University of Western Ontario in London.
Family physicians, other primary health care providers, and the Deliver Primary Healthcare Information management and operations team.
The findings of 3 separate qualitative studies exploring the implementation of EHRs were synthesized. In the 3 studies, investigators used semistructured interview guides to conduct one-on-one interviews and a focus group, which were audiotaped and transcribed verbatim, to collect information about participants’ experiences implementing and adopting EHRs. Transcripts were coded and analyzed by 1 or 2 investigators, and the research team met regularly for synthesis and interpretation of themes.
Four common themes arose from the 3 studies: expectations of EHRs, time and training required to implement and adopt the software, the emergence of an EHR champion or problem solver, and the readiness of health care providers to accept the system.
Those considering implementing and adopting EHRs into a family practice environment should reflect on the following issues: their expectations of the system and what is needed to use the software, the level of commitment to EHR implementation and adoption, the availability of someone willing to take a leadership or champion role, and how much knowledge of computers potential EHR users have.
Providing patients with access to their electronic health records offers great promise to improve patient health and satisfaction with their care, as well to improve professional and organizational approaches to health care. Although many benefits have been identified, there are many questions about best practices for the implementation of patient accessible Electronic Health Records (EHRs).
To develop recommendations to assist health care organizations in providing patients with access to EHRs in a meaningful, responsible, and responsive manner.
A Patient Accessible Electronic Health Record (PAEHR) Workshop was held with nationally and internationally renowned experts to explore issues related to providing patient access to the EHR and managing institutional change.
The PAEHR Workshop was attended by 45 participants who discussed recommendations for the implementation of patient accessible EHRs. Recommendations were discussed under four subject domains: (1) providing patient access to the EHR, (2) maintaining privacy and confidentiality related to the PAEHR, (3) patient education and navigation of the PAEHR, and (4) strategies for managing institutional change. The discussion focused on the need for national infrastructure, clear definitions for privacy, security and confidentiality, flexible, interoperable solutions, and patient and professional education. In addition, there was a strong call for research into all domains of patient accessible EHRs to ensure the adoption of evidence-based practices.
Patient access to personal health information is a fundamental issue for patient engagement and empowerment. Health care professionals and organizations should consider the potential benefits and risks of patient access when developing EHR strategies. Flexible, standardized, and interoperable solutions must be integrated with outcomes-based research to activate effectively patients as partners in their health care.
Electronic Health Record (EHR); Personal Health Record (PHR); medical records; recommendations; health planning guidelines; access; access to information
Patients with chronic conditions often use complex medical regimens. A nurse‐led strategy to support medication therapy management incorporated into primary care teams may lead to improved use of medications for disease control. Electronic health record (EHR) tools may offer a lower‐cost, less intensive approach to improving medication management.
Methods and Results
The Northwestern and Access Community Health Network Medication Education Study is a health center–level cluster‐randomized trial being conducted within a network of federally qualified community health centers. Health centers have been enrolled in groups of 3 and randomized to (1) usual care, (2) EHR‐based medication management tools alone, or (3) EHR tools plus nurse‐led medication therapy management. Patients with uncontrolled hypertension who are prescribed ≥3 medications of any kind are recruited from the centers. EHR tools include a printed medication list to prompt review at each visit and automated plain‐language medication information within the after‐visit summary to encourage proper medication use. In the nurse‐led intervention, patients receive one‐on‐one counseling about their medication regimens to clarify medication discrepancies and identify drug‐related concerns, safety issues, and nonadherence. Nurses also provide follow‐up telephone calls following new prescriptions and periodically to perform medication review. The primary study outcome is systolic blood pressure after 1 year. Secondary outcomes include measures of understanding of dosing instructions, discrepancies between patient‐reported medications and the medical record, adherence, and intervention costs.
The Northwestern and Access Community Health Network Medication Education Study will assess the effects of 2 approaches to support outpatient medication management among patients with uncontrolled hypertension in federally qualified health center settings.
Clinical Trial Registration
URL: clinicaltrials.gov. Unique identifier: NCT01578577.
adherence; electronic health records; hypertension; medication reconciliation; medication therapy management; nurse educator
The aim of this study was to examine the effect of having a basic electronic health record (EHR) on nurse-assessed quality of care, including patient safety. Few large-scale studies have examined how adoption of EHRs may be associated with quality of care. A cross-sectional, secondary analysis of nurse and hospital survey data was conducted. The final sample included 16,352 nurses working in 316 hospitals in 4 states. Logistic regression models were used to evaluate the relationship between basic EHR adoption and nurse-assessed quality of care outcomes. Nurses working in hospitals with basic EHRs consistently reported that poor patient safety and other quality outcomes occurred less frequently than reported by nurses working in hospitals without an EHR. Our findings suggest that the implementation of a basic EHR may result in improved and more efficient nursing care, better care coordination, and patient safety.
Electronic health records (EHRs) have been implemented throughout the United States with varying degrees of success. Past EHR implementation experiences can inform health systems planning to initiate new or expand existing EHR systems. Key “critical success factors,” e.g., use of disease registries, workflow integration, and real-time clinical guideline support, have been identified but not fully tested in practice.
A pre/postintervention cohort analysis was conducted on 495 adult patients selected randomly from a diabetes registry and followed for 6 years. Two intervention phases were evaluated: a “low-dose” period targeting primary care provider (PCP) and patient education followed by a “high-dose” EHR diabetes management implementation period, including a diabetes disease registry and office workflow changes, e.g., diabetes patient preidentification to facilitate real-time diabetes preventive care, disease management, and patient education.
Across baseline, “low-dose,” and “high-dose” postintervention periods, a significantly greater proportion of patients (a) achieved American Diabetes Association (ADA) guidelines for control of blood pressure (26.9 to 33.1 to 43.9%), glycosylated hemoglobin (48.5 to 57.5 to 66.8%), and low-density lipoprotein cholesterol (33.1 to 44.4 to 56.6%) and (b) received recommended preventive eye (26.2 to 36.4 to 58%), foot (23.4 to 40.3 to 66.9%), and renal (38.5 to 53.9 to 71%) examinations or screens.
Implementation of a fully functional, specialized EHR combined with tailored office workflow process changes was associated with increased adherence to ADA guidelines, including risk factor control, by PCPs and their patients with diabetes. Incorporation of previously identified “critical success factors” potentially contributed to the success of the program, as did use of a two-phase approach.
chronic disease management; diabetes; EHR; health information technology
The increasing adoption of electronic health records (EHRs) due to Meaningful Use is providing unprecedented opportunities to enable secondary use of EHR data. Significant emphasis is being given to the development of algorithms and methods for phenotype extraction from EHRs to facilitate population-based studies for clinical and translational research. While preliminary work has shown demonstrable progress, it is becoming increasingly clear that developing, implementing and testing phenotyping algorithms is a time- and resource-intensive process. To this end, in this manuscript we propose an efficient machine learning technique—distributional associational rule mining (ARM)—for semi-automatic modeling of phenotyping algorithms. ARM provides a highly efficient and robust framework for discovering the most predictive set of phenotype definition criteria and rules from large datasets, and compared to other machine learning techniques, such as logistic regression and support vector machines, our preliminary results indicate not only significantly improved performance, but also generation of rule patterns that are amenable to human interpretation
The Veterans Health Administration (VA) has invested significant resources in designing and implementing a comprehensive electronic health record (EHR) that supports clinical priorities. EHRs in general have been difficult to implement, with unclear cost-effectiveness. We describe VA clinical personnel interactions with and evaluations of the EHR.
As part of an evaluation of a quality improvement initiative, we interviewed 72 VA clinicians and managers using a semi-structured interview format. We conducted a qualitative analysis of interview transcripts, examining themes relating to participants' interactions with and evaluations of the VA EHR.
Participants described their perceptions of the positive and negative effects of the EHR on their clinical workflow. Although they appreciated the speed and ease of documentation that the EHR afforded, they were concerned about the time cost of using the technology and the technology's potential for detracting from interpersonal interactions.
VA personnel value EHRs' contributions to supporting communication, education, and documentation. However, participants are concerned about EHRs' potential interference with other important aspects of healthcare, such as time for clinical care and interpersonal communication with patients and colleagues. We propose that initial implementation of an EHR is one step in an iterative process of ongoing quality improvement.
Community health centers (CHCs) face a unique set of challenges and can learn much from each other as they prepare for the adoption of health information technology (HIT).
This paper presents a research agenda aimed at providing information CHCs will need to successfully implement HIT.
Community health centers must be able to evaluate whether an investment in HIT is the best way to achieve improvements in health outcomes for their communities given the limited resources and high demands they face. Community health centers need better information to guide them in selecting and implementing information technology that will result in improved health quality and safety. Guidance in optimal use of the system, particularly in the effective use of data made available through electronic health records, is needed to realize health care goals. Community health centers need to be active participants in HIT developments in their communities to ensure that their patients benefit from technological advancements that improve health care.
electronic health records; health information technology; community health centers; health care quality; health care safety
To optimally leverage the scalability and unique features of the electronic health records (EHR) for research that would ultimately improve patient care, we need to accurately identify patients and extract clinically meaningful measures. Using multiple sclerosis (MS) as a proof of principle, we showcased how to leverage routinely collected EHR data to identify patients with a complex neurological disorder and derive an important surrogate measure of disease severity heretofore only available in research settings.
In a cross-sectional observational study, 5,495 MS patients were identified from the EHR systems of two major referral hospitals using an algorithm that includes codified and narrative information extracted using natural language processing. In the subset of patients who receive neurological care at a MS Center where disease measures have been collected, we used routinely collected EHR data to extract two aggregate indicators of MS severity of clinical relevance multiple sclerosis severity score (MSSS) and brain parenchymal fraction (BPF, a measure of whole brain volume).
The EHR algorithm that identifies MS patients has an area under the curve of 0.958, 83% sensitivity, 92% positive predictive value, and 89% negative predictive value when a 95% specificity threshold is used. The correlation between EHR-derived and true MSSS has a mean R2 = 0.38±0.05, and that between EHR-derived and true BPF has a mean R2 = 0.22±0.08. To illustrate its clinical relevance, derived MSSS captures the expected difference in disease severity between relapsing-remitting and progressive MS patients after adjusting for sex, age of symptom onset and disease duration (p = 1.56×10−12).
Incorporation of sophisticated codified and narrative EHR data accurately identifies MS patients and provides estimation of a well-accepted indicator of MS severity that is widely used in research settings but not part of the routine medical records. Similar approaches could be applied to other complex neurological disorders.
Building upon the foundation of the Structured Narrative electronic health record (EHR) model, we applied theory-based (combined Technology Acceptance Model and Task-Technology Fit Model) and user-centered methods to explore nurses’ perceptions of functional requirements for an electronic nursing documentation system, design user interface screens reflective of the nurses’ perspectives, and assess nurses’ perceptions of the usability of the prototype user interface screens. The methods resulted in user interface screens that were perceived to be easy to use, potentially useful, and well-matched to nursing documentation tasks associated with Nursing Admission Assessment, Blood Administration, and Nursing Discharge Summary. The methods applied in this research may serve as a guide for others wishing to implement user-centered processes to develop or extend EHR systems. In addition, some of the insights obtained in this study may be informative to the development of safe and efficient user interface screens for nursing document templates in EHRs.
Electronic Nursing Documentation; User Interface; Functional Requirements; Nursing Documentation Templates; User-Centered Approach; Clinical Document Architecture; Document Ontology; Technology Acceptance Model; Task-Technology Fit model
There has been little discussion of or research on the key translational issue of how to integrate patient self-management programs across multiple primary care clinics within an HMO. The purpose of this study was to summarize our experiences and lessons learned in trying to integrate information from a web-based diabetes self-management program into primary care and the electronic health record (EHR). We describe plans, implementation, adaptations made, and data on patient and physician reactions to the My Path diabetes self-management program provided to 331 adult primary care patients. Mixed methods results revealed that, despite the availability of a state-of-the-art EHR, the intervention was not well integrated into primary care. Information from health-promotion and disease management programs, even within the same organization and with advanced EHR systems, is challenging to integrate into busy primary care.
Implementation; Primary care; Chronic disease self-management; Integration; Health technology
Challenges in implementing electronic health records (EHRs) have received some attention, but less is known about the process of transitioning from legacy EHRs to newer systems.
To determine how ambulatory leaders differentiate implementation approaches between practices that are currently paper-based and those with a legacy EHR system (EHR-based).
Eleven practice managers and 12 medical directors all part of an academic ambulatory care network of a large teaching hospital in New York City in January to May of 2006.
Qualitative approach comparing and contrasting perceived benefits and challenges in implementing an ambulatory EHR between practice leaders from paper- and EHR-based practices. Content analysis was performed using grounded theory and ATLAS.ti 5.0.
We found that paper-based leaders prioritized the following: sufficient workstations and printers, a physician information technology (IT) champion at the practice, workflow education to ensure a successful transition to a paperless medical practice, and a high existing comfort level of practitioners and support staff with IT. In contrast, EHR-based leaders prioritized: improved technical training and ongoing technical support, sufficient protection of patient privacy, and open recognition of physician resistance, especially for those who were loyal to a legacy EHR. Unlike paper-based practices, EHR-based leadership believed that comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome.
Leadership at paper- and EHR-based practices in 1 academic network has different priorities for implementing a new EHR. Ambulatory practices upgrading their legacy EHR have unique challenges.
electronic health records (EHR); implementations; challenges; ambulatory
Developing a clinically relevant set of quality measures that can be effectively used by an electronic health record (EHR) is difficult. Whether it is achieving internal consensus on relevant priority quality measures, communicating to EHR vendors' whose programmers generally lack clinical contextual knowledge, or encouraging implementation of EHR that meaningfully impacts health outcomes, the path is challenging. However, greater transparency of population health, better accountability, and ultimately improved health outcomes is the goal and EHRs afford us a realistic chance of reaching it in a scalable way.
In this article, we summarize our experience as a public health government agency with developing measures for a public health oriented EHR in New York City in partnership with a commercial EHR vendor.
From our experience, there are six key lessons that we share in this article that we believe will dramatically increase the chance of success. First, define the scope and build consensus. Second, get support from executive leadership. Third, find an enthusiastic and competent software partner. Fourth, implement a transparent operational strategy. Fifth, create and test the EHR system with real life scenarios. Last, seek help when you need it.
Despite the challenges, we encourage public health agencies looking to build a similarly focused public health EHR to create one both for improved individual patient as well as the larger population health.
Implementing electronic health records (EHR) in healthcare settings incurs challenges, none more important than maintaining efficiency and safety during rollout. This report quantifies the impact of offloading low-acuity visits to an alternative care site from the emergency department (ED) during EHR implementation. In addition, the report evaluated the effect of EHR implementation on overall patient length of stay (LOS), time to medical provider, and provider productivity during implementation of the EHR. Overall LOS and time to doctor increased during EHR implementation. On average, admitted patients' LOS was 6–20% longer. For discharged patients, LOS was 12–22% longer. Attempts to reduce patient volumes by diverting patients to another clinic were not effective in minimizing delays in care during this EHR implementation. Delays in ED throughput during EHR implementation are real and significant despite additional providers in the ED, and in this setting resolved by 3 months post-implementation.
Electronic health record; implementation; pediatrics; provider efficiency
A primary goal for the development of EHRs and EHR-related technologies should be to facilitate greater knowledge management for improving individual and community health outcomes associated with HIV / AIDS. Most of the current developments of EHR have focused on providing data for research, patient care and prioritization of healthcare provider resources in other areas. More attention should be paid to using information from EHRs to assist local, state, national, and international entities engaged in HIV / AIDS care, research and prevention strategies. Unfortunately the technology and standards for HIV-specific reporting modules are still being developed.
A literature search and review supplemented by the author’s own experiences with electronic health records and HIV / AIDS prevention strategies will be used. This data was used to identify both opportunities and challenges for improving public health informatics primarily through the use of latest innovations in EHRs. Qualitative analysis and suggestions are offered for how EHRs can support knowledge management and prevention strategies associated with HIV infection.
EHR information, including demographics, medical history, medication and allergies, immunization status, and other vital statistics can help public health practitioners to more quickly identify at-risk populations or environments; allocate scarce resources in the most efficient way; share information about successful, evidenced-based prevention strategies; and increase longevity and quality of life.
Local, state, and federal entities need to work more collaboratively with NGOs, community-based organizations, and the private sector to eliminate barriers to implementation including cost, interoperability, accessibility, and information security.
Usability of Health Information; Information Technology; Health Promotion / Disease Prevention; HIV; Acquired Immunodeficiency Syndrome; Public Health Informatics; Electronic Health Records; Knowledge Management
A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments’ healthcare reform strategies. The resulting politically-initiated large-scale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money.
Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England’s National Health Service’s Care Records Service (NHS CRS).
We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations → intervention → changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions.
New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.
Electronic health record (EHR); Evaluation; Methodology; Sociotechnical; Changing; NHS CRS; Adaptation; Reflexivity